Finding great GPs and fantastic hospitals

[Today's announcement by the Health Secretary will be of interest to all those using, following, or already working with, iWantgreatcare. As you are aware, the iWantgreatcare service is the only way for the UK public to get information on individual doctors to help them choose great care for themselves and their families.]

As Andy Burnham said today, the NHS is good, but needs to be great.

In fact, much of the NHS is not even good - but parts of it are fantastic.

Harnessing the experience and views of patients and their relatives is the key to driving out the poor, building on the good, and identifying the fantastic - this is the central truth underpinning iWantGreatCare.

But today's speech by the Secretary of State is important in announcing the overdue policy change that will allow the power of patients to drive the quality improvements that can make the NHS great. By giving patients the ability to choose who cares for them, and by linking hospital budgets to patient experience, those delivering care who do not focus on the total satisfaction and experience of their patients will be exposed, will lose patients and will lose funding. They will improve - or be replaced by better services, delivering better quality care.

With free choice over who cares for themselves and their family, patients will seek out the information to make informed decisions. NHS Choices, iWantGreatCare and others will meet this need, empowering patients and allowing them to find truly great care. Indeed, the thousands of patients already using iWantGreatCare shows the scale of public demand for transparent, independent knowledge about the quality and experience of healthcare - and the unique way in which users value the views and experiences of their fellow patients.

The best NHS Trusts, doctors and hospitals know this already and are using new ways to capture, understand and use patient experience to improve quality, reduce costs and ensure total focus on the needs of their patients. iWantGreatCare already works with some of the UK's most innovative healthcare providers; NHS Trusts who know that continuously capturing and understanding real-time patient experience from thousands of users, every day of the year, across all the services they deliver is the key to quality improvement. These are organisations not afraid of the suggestions and criticisms of users, but who actively encourage and facilitate such feedback, seeing all comments as opportunities to correct and improve everything they do.

Today's announcement shows that they (and their patients) will be the winners.

Transformational power of crowd sourcing and patient choice

Enabling meaningful choice and using this as a driver for improvement from providers.

Patient Choice is not just valuable in its own right as an enabler of patient-centric care, but has the (as yet unfulfilled) potential to drive transformational quality improvement by creating internal NHS competition.

Patients and the public are currently unable to make informed choice and thus cannot exert the pressure required to drive patient-centric change. Nothing currently being delivered in NHS looks capable of changing this.

In the same way that IT-enabled visualisation and understanding of performance for Boards and staff changes culture, so the same will be true for huge numbers of NHS patients. This requires a far more innovative approach than employed to date - but will benefit from the same technologies and understanding employed by many other industries which focus on empowering and supporting users by enabling them to understand realities behind often complex data sets.

Once users understand the huge variance across the NHS, they will exercise choice - and this will create positive pressure for change and improvement across the service.

Existing traditional approaches (doing what we do now in a better way) have failed to harness this potential and will continue to do so.

Is it time to unleash the “armchair auditors”, time to trust the patients and users of the NHS to be the prime judges of the service they pay for, and to fully share this information and opinion in a transparent and open way?

Analysis of - “Understanding what matters” (Department of Health)

iWantGreatCare’s ‘Analysis Of...’ series (1) - 'From Ward to Board'

This is the first post in the ‘Analysis Of...’ series; stuctured commentary on salient publications, conferences and newspaper articles related to patient experience monitoring, analysis and improvement. There will be an ever increasing volume of discussion across many channels in the patient experience space and this series will carefully select out the most relevant, most controversial or the most authoritative and look at them in more detail. The structure for ‘taking a closer look’, and one that will become familiar to readers is Cut it, Dissect it, Digest it, Rate it.

First in the series is a publication from the Department of Health titled Understanding what matters: A guide to using patient feedback to transform services (May 2009). This is a good publication with which to kick off this series since it is recent and topical. It also presents a well written, comprehensive guide to the labyrinth that patient experience can be to some. The publication title is somewhat long winded and for brevity will be referred to as ‘the guide’ from now on...

CUT IT? (i.e. does it ‘cut it’?)– Yes it does. This is a timely piece. The interest in, and activity around, patient experience is rising and many are jumping on this wagon with no clinical background or understanding. The risk of such opportunism is that valid patient experience measurement is not acheived, and the importance and power of unlocking the voice of patients is not given the priority it deserves. There is no time to be wasted with “making it up as you go along” or deploying non-specialised providers for what is a highly specialised area. The impending pressure on budgets, and consequent cuts in services, could have a profound effect on patient experience, and rigorous baseline measurements must be put in place with out delay.

The guide is a comprehensive account, touching on all the main themes in patient experience: capture, analysis, feedback and action. Only one problem with guides – they are like torches in a drawer on a dark night: someone needs to switch them on.

DISSECT IT – The guide notes that patient experience is still very hospital focussed and needs to be widened across PCTs, including community care. Although hospitals may be doing some patient satisfaction surveying and complaints handling, only a few are doing adequate patient experience ‘tracking’. The granularity of the data being collected is at best limited to ward or department level, reducing the ability to use the information to deliver the behaviour and culture changes necessary for sustained improvements. Moreover, patients and carers should be offered simpler means of rating the services they use; tracking experience on hand held pads is far from adequate to collect the detail and quantities of data required. The evidence base suggests that patient perception is mostly influenced by the individual clinician or carer and thus assessing experience at this level is key. Implementing such systems requires clinical engagement as a core component for the success of patient experience performance management programmes.
Case examples throughout the guide provide illustrative detail and meaning and are recommended.

DIGEST IT – The guide touches on the essential principles of patient experience but since it is a guide and not a ‘how to manual’ it does not go into detail. The first issue is the benefits to be gained from excellent monitoring of patient experience. Board directors need to fully understand these principles: business cases and investment papers need to demonstrate the full value justification over time; a business case for patient experience which simply puts forward a ‘plug and play’ type technology acquisition will not work.
Another area not covered in the guide is the importance of local media engagement as part of any patient experience programme. This has to be done to promote and celebrate success within local communities. Brand building for the local NHS can be powerfully worked out of good media engagement.

The guide also warns readers to be conscious of the need to get ethical approval for conducting patient experience research. The ethical issues and consideration of patients is paramount and should always be considered carefully. However, there are effective ways to do this whilst still maintaining momentum and the speed required to deliver rapid benefits in patient experience programmes. iWantGreatCare is particularly interested in research to fully understand the links between patient experience and safety, and patient experience and clinical outcomes. The skill will be to combine this academic base whilst rapidly addressing the new wave of consumer-driven healthcare; doing this now, both for and WITH patients and carers.

RATE IT ****

Meaningful measurement - time to turn words into actions

Measuring quality - the fundamental first-step in improving quality
The majority of NHS organisations (and individuals) have no accurate and timely way to measure their performance, nor to compare it with other providers.
In contrast to organisations in the commercial sector, whether at board level (exec and non-exec), through management to clinical, front-line staff there is no rigorous, valid way to allow direct, continuous assessment of the quality of care delivered.

The need to measure quality is more urgent than ever before, due to the reorganisation of services that will be required as a result of budgetary pressures post 2011. To be sure that quality is maintained requires it to be measured before, during and after any changes. Without this organisations are deluding themselves if they think they can be confident about quality of service.

Warning - Merely collecting data on clinical outcomes alone is inadequate:
a. In the majority of clinical areas the quality data required is simply unavailable
b. The Mid-Staffordshire disaster shows that current data sets collected are wholly inadequate to accurately monitor service provision with the granularity or timeliness required - Mid-Staffs data was insufficient for the Chief Exec, non-execs, clinical staff, Monitor or the HCC to have visibility of reality
c. Clinical outcomes alone are only half of the equation (quality = outcomes X experience). The NHS cannot understand or assess quality until patient experience is approached with the same seriousness and importance as is monitoring and response to hospital-acquired infection. This requires new thinkning and innovative use of IT driven systems to collect and visualise the data
d. Data itself has little or no value - impact on organisational performance and quality are only realised when the information is accessible, understood and integrated in the systems and processes of the organisation, e.g. enables culture-change. When this is achieved it is proven to deliver improved outcomes, decreased litigation and decreased staff-turnover - all massive clinical and financial benefits to the NHS and patients.

Thus the challenge (and opportunity) is how to provide every NHS (and private-sector) organisation with the insight and understanding required to measure and improve quality. Successfully enabling this will reveal areas of quality excellence, as well as rapidly and accurately identifying areas for improvement.

The Emperor's new clothes

Everyone said, loud enough for the others to hear: "Look at the Emperor's new clothes. They're beautiful! What a marvellous train! And the colors! The colors of that beautiful fabric! I have never seen anything like it in my life!"

A child, however, who had no important job and could only see things as his eyes showed them to him, went up to the carriage. "The Emperor is naked," he said.



The quality of healthcare in the NHS is highly variable.
Some if it is excellent, most of it is average (by definition of course), and some of it is bad.
Some of it is bad.

This last point needs repetition, because unless everybody recognises and accepts this - and keeps talking about it - things will never get better.

Patients and their carers need to talk about it, healthcare professionals (especially doctors) need to talk about it loudly, and providers need to make it their job to talk about the good and bad parts of their services.

Most importantly, but most unlikely to happen, is that the government and Department of Health need to not only accept it, but to shout loudly about the huge and unacceptable variation in quality (outcomes and experience) that the NHS delivers - and to tell every tax-payer whether their local GPs and hospitals are great, average or poor.

However to do this politicians (thinking about forthcoming elections?) have to tell the public that despite huge investment in the NHS:
1. No one can really tell you where or who gives the best care (or the worst)
2. You may be getting care which is unacceptably bad.

Just like MPs expenses, the only thing that will lead to the "root and branch" change essential to improve the NHS is total transparency about variation in quality, and identifying publicly the places (and individuals) that deliver great care, and those that absolutely do not. When done properly, this will allow the power of patients to drive the transformation that the DH, NHS and doctors have failed to do. Of course some of this is difficult, and it will lead to a lot of painful change but that is no reason not to do it.

And if anyone dare tell you that this is already being done, you might remind them that the Mid-Staffs Hospital was rated as "Good" and Monitor allowed it to become a Foundation Hospital - in the years that at least 400 people died unnecessarily on its wards.

What would the child, "who had no important job and could only see things as his eyes showed them to him", say?

"The days of suffering in silence will soon be over..."

According to the Times. They quote Lord Adonis: "this new requirement gives [users] a direct and much louder voice on whether their needs are being met".

Rude staff, dirty facilities, unacceptable waiting times, provision of information will all now be measured and reported by users themselves - with providers failing to meet standards subject to fines of up to £500,000/year.

Sounds wonderful, and well overdue. However, this is for rail passengers - not for patients and their families.

Interesting to ponder why a government that claims health to be a central priority, decides to give the public power and a voice to help improve standards of trains, before enabling such powerful involvement in improving healthcare and the NHS.

But those committed to improving the NHS do not need to worry of course: the regulation announced by Lord Adonis is an example of the changes that will affect all industries and professions and indeed already has done so for many. The provision of healthcare will benefit more than most sectors by enabling true involvement of users, and harnessing the power and wisdom of patients to help organisations deliver truly great care. Just a shame to see doctors lagging far behind other professional groups in welcoming and leading these transformational potentials.

Standardisation should be standard

As reported by the HSJ, "The Department of Health will not impose standards for “real time” measurement of patients’ experience, despite pressure to use results to help identify failing trusts.
Guidance will be published on the use of fast-turnaround feedback, which many hospital trusts are beginning to collect, in coming weeks.
But there will be no standard collection methods, questions or measures, meaning the results cannot be used for national benchmarking, performance management or patient choice."

Reasons this is the wrong decision:
1. Patients and carers want and need comparative data on experience to guide their decisions and enable informed choice.
2. Only comparative data allows organisations and individuals to see how well they are really doing - or not. Remember, the CEO at Mid -Staffs (and presumably his board and senior medical staff) thought all was well...
3. Great staff want to know how they are performing against their peers across the country - not just down the corridor.
4. Without national standardisation, experience data is close to useless - imagine we allowed infection rates to be reported with each hospital using their own measurement and no way to compare one with the other, or perhaps allowed every surgeon to decide her own scales for success and to report using their "My personal outcome score".
5. It allows mediocrity to hide, and fails to highlight the excellence that others can learn from.


Reasons this decision doesn't matter:
1. Patients and carers will find ways to compare: talking to each other, talking to doctors and nurses, using the internet to share and compare experience.
2. The very best Trusts are already developing ways to compare themselves with other great organisations - great leaders know that this is the only way to deliver excellence.
3. Local leadership and the devolved power of PCTs and Foundation Trusts ensures that organisations which understand quality, and which pay more than lip-service to "patient-centric care", will find ways to deliver comparative data because they understand that without it there is no true choice.
4. iWantGreatCare already allows patients and providers to collect, understand and use true, comparative data in the pursuit of excellent healthcare.